About this Book

Beyond the Book:Persistent Cloaca

Miss Jane is based on Brad Watson's great-aunt's life. She, like the central character in his novel, suffered from a genital birth defect. But what exactly was it?

In an interview at W.W. Norton, Watson says:

As was common in her day (she actually lived from 1888-1975, but it applies to my Jane's day and time, too), no one really talked about it. And so no one alive by the time I came into the world really knew "what was wrong with Aunt Jane." One of the more difficult parts of my research was figuring out what her condition may have been. I had little to go on: her known incontinence, and a late discovery that she had only one opening for the elimination of waste, which led me down a long path of crossing out this and that possibility. Based on those two facts, and some things I learned doing research, and the fact that she lived a long and apparently otherwise healthy life, I finally decided she probably had something called persistent cloaca, a rare condition that occurs only in females and only in about 1 in 20,000-25,000 births.

As a baby develops in utero, three openings are supposed to evolve to become the urinary, genital and intestinal tracts. Before this separation, the three are joined together in a sac called cloaca. If they fail to separate  as was probably the case for Watson's great-aunt  the result is the condition called persistent cloaca.

The condition is most often discovered at birth. Along with just having one opening, the newborn may also have abdominal swelling. An ultrasound can show the specific location of the swelling (in the rectum, vagina and bladder.) X-rays and an endoscopy further illuminate what can not be seen, and an MRI of the pelvis and spine are often done to look for spinal defects. These days, surgery can be done to repair and reconstruct these openings. A colostomy is often needed first. Catheterization is needed as well, to drain urine. Reconstruction happens after the child's anatomy is clearly defined, which occurs at around 6 months to a year old. The one opening is divided into three. In mild cases of persistent cloaca the end result is nearly normal control of bodily functions. More severe cases can result in occasional to persistent leaking, and some need further self-catheterization. After surgery, normal sexual activity is possible.

None of these diagnostic tests or surgeries were available, of course, when Miss Jane was born. As Watson writes, "Miss Jane" was born into that time and place, in the farmland cut from the pine and broadleaf woods of east-central Mississippi, 1915, when there was no possibility of doing anything to alleviate her condition, no medical procedure to correct it It was something to be accepted, grim-faced, as they accepted crop failure, debt, poverty, the frequent deaths of infants and small children from fevers and other maladies." Although Jane ultimately finds her own way to lead a full and fulfilling life, modern science and medicine have paved the way, thankfully, for girls and women to have an easier time of it.

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